Proposed

WSR 12-21-112 Washington State Register, Issue 12-21
(5) The ((department)) agency pays MCOs a delivery
case rate, separate from the capitation payment, when an
enrollee delivers a child(ren) and the MCO pays for any part
of labor and delivery.
AMENDATORY SECTION (Amending WSR 11-14-075,
filed 6/30/11, effective 7/1/11)
WAC 182-538-095 Scope of care for managed care
enrollees. (1) Managed care enrollees are eligible for the
scope of ((medical care)) services as described in WAC
((388-501-0060)) 182-501-0060 for categorically needy clients.
(a) A client is entitled to timely access to medically necessary
services as defined in WAC ((388-500-0005)) 182-
500-0070.
(b) The managed care organization (MCO) covers the
services included in the MCO contract for MCO enrollees.
MCOs may, at their discretion, cover additional services not
required under the MCO contract. However, the ((department))
agency may not require the MCO to cover any additional
services outside the scope of services negotiated in the
MCO's contract with the ((department)) agency.
(c) The ((department)) agency covers medically necessary
services described in WAC ((388-501-0060 and 388-
501-0065)) 182-501-0060 and 182-501-0065 that are
excluded from coverage in the MCO contract.
(d) The ((department)) agency covers services through
the fee-for-service system for enrollees with a primary care
case management (PCCM) provider. Except for emergencies,
the PCCM provider must either provide the covered services
needed by the enrollee, or refer the enrollee to other providers
who are contracted with the ((department)) agency for covered
services. The PCCM provider is responsible for instructing
the enrollee regarding how to obtain the services that are
referred by the PCCM provider. Services that require PCCM
provider referral are described in the PCCM contract. The
((department)) agency informs an enrollee about the
enrollee's program coverage, limitations to covered services,
and how to obtain covered services.
(e) MCO enrollees may obtain specific services
described in the managed care contract from either an MCO
provider or from a provider with a separate agreement with
the ((department)) agency without needing to obtain a referral
from the PCP or MCO. These services are communicated
to enrollees by the ((department)) agency and MCOs as
described in (f) of this subsection.
(f) The ((department)) agency sends each client written
information about covered services when the client is
required to enroll in managed care, and any time there is a
change in covered services. This information describes covered
services, which services are covered by the ((department))
agency, and which services are covered by MCOs. In
addition, the ((department)) agency requires MCOs to provide
new enrollees with written information about covered
services.
(2) For services covered by the ((department)) agency
through PCCM contracts for managed care:
(a) The ((department)) agency covers medically necessary
services included in the categorically needy scope of
Proposed [ 136 ]
care and rendered by providers who have a current core provider
agreement with the ((department)) agency to provide
the requested service;
(b) The ((department)) agency may require the PCCM
provider to obtain authorization from the ((department))
agency for coverage of nonemergency services;
(c) The PCCM provider determines which services are
medically necessary;
(d) An enrollee may request a hearing for review of
PCCM provider or ((the department)) agency coverage decisions
(see WAC ((388-538-110)) 182-538-110); and
(e) Services referred by the PCCM provider require an
authorization number in order to receive payment from the
((department)) agency.
(3) For services covered by the ((department)) agency
through contracts with MCOs:
(a) The ((department)) agency requires the MCO to subcontract
with a sufficient number of providers to deliver the
scope of contracted services in a timely manner. Except for
emergency services, MCOs provide covered services to
enrollees through their participating providers;
(b) The ((department)) agency requires MCOs to provide
new enrollees with written information about how enrollees
may obtain covered services;
(c) For nonemergency services, MCOs may require the
enrollee to obtain a referral from the primary care provider
(PCP), or the provider to obtain authorization from the MCO,
according to the requirements of the MCO contract;
(d) MCOs and their contracted providers determine
which services are medically necessary given the enrollee's
condition, according to the requirements included in the
MCO contract;
(e) The ((department)) agency requires the MCO to coordinate
benefits with other insurers in a manner that does not
reduce benefits to the enrollee or result in costs to the
enrollee;
(f) A managed care enrollee does not need a PCP referral
to receive women's health care services, as described in RCW
48.42.100, from any women's health care provider participating
with the MCO. Any covered services ordered and/or prescribed
by the women's health care provider must meet the
MCO's service authorization requirements for the specific
service.
(g) For enrollees temporarily outside their MCO services
area, the MCO is required to cover enrollees ((for up to ninety
days)) for emergency care and medically necessary covered
benefits that cannot wait until the enrollees return to their
MCO services area.
(4) Unless the MCO chooses to cover these services, or
an appeal, ((independent review,)) or a hearing decision
reverses an MCO or ((department)) agency denial, the following
services are not covered:
(a) For all managed care enrollees:
(i) Services that are not medically necessary(([.])) as
defined in WAC 182-500-0070.
(ii) Services not included in the categorically needy
scope of services.
(iii) Services, other than a screening exam as described
in WAC ((388-538-100)) 182-538-100(3), received in a hos-